title: Exposure during pancreatic surgery. Do we have to examine the falciform and round ligaments for pancreatic cancer metastasis?
abstract: BACKGROUND
  Metastatic and locally advanced disease is unfortunately a common clinical occurrence in patients affected by pancreatic cancer. The most frequent sites of metastasis are the liver and the peritoneal lining. The falciform and round ligaments are routinely resected and sent for pathology, but no metastases have ever been reported.
  
  
  OBJECTIVE
  In this study, we assess whether the falciform and round ligaments are possible sites for metastases and if routine pathology examination of these structures is justified.
  
  
  METHODS
  Retrospective, single institution study.
  
  
  METHODS
  The charts of all patients who underwent pancreatic resection from June 2005 through January 2011 were reviewed retrospectively. Data on age, gender, type of operation performed, preoperative CA 19-9 levels, vascular and perineural invasion, tumor differentiation and pathological staging were retrieved from the hospital electronic data base. Only patients with malignant lesions of the pancreas were included in the study.
  
  
  METHODS
  Presence of pancreatic metastasis in the falciform and round ligaments.
  
  
  RESULTS
  Fifty-seven patients were included in the study. Forty patients had undergone pancreaticoduodenectomies, 10 subtotal pancreatectomies, 2 total pancreatectomies, and 1 distal pancreatectomy. Four patients had exploratory laparotomy but exploration revealed stage III or IV disease, thus the planned resection was not carried out. The falciform and round ligaments were all negative for metastasis in all patients.
  
  
  CONCLUSIONS
  Metastatic progression of pancreatic cancer is poorly understood. Theoretically, metastases to the falciform and round ligaments could occur by either contiguous, hematogenic or lymphatic spread. In our study, none of the patients had metastases to the falciform and round ligaments, regardless of the pathological staging.
  
  
  CONCLUSIONS
  We concluded that routine pathological examination of the falciform and round ligaments is not justified if the surgeon elects to remove the structures for ease of exploration and retraction during surgery. This may lighten the workload and reduce costs in a busy pathology laboratory.
authors.affiliation: Department of General Surgery, Rambam Health Care Campus. Haifa, Israel. o_ben-ishay@rambam.health.gov.il
authors.forename: Offir
authors.initials: O
authors.lastname: Ben-Ishay
authors.forename: Arie
authors.initials: A
authors.lastname: Ariche
authors.forename: Jesse
authors.initials: J
authors.lastname: Lachter
authors.forename: Yoram
authors.initials: Y
authors.lastname: Kluger
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000032:analysis; D018395:CA-19-9 Antigen / Q000032:analysis; D005260:Female; D006801:Humans; D008022:Ligaments / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis / Q000175:diagnosis*; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000378:metabolism / Q000473:pathology* / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D012189:Retrospective Studies; D012404:Round Ligament of Uterus / Q000473:pathology; D012680:Sensitivity and Specificity
chemical_list: D014408:Biomarkers, Tumor; D018395:CA-19-9 Antigen